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APPLICATION FOR PERMIT IE `Sr <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • 1601 E. HAZELiON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / i <br /> (Complete in Triplicate) (� <br /> /or install the work <br /> This <br /> cation is <br /> madein(compliance w made <br /> Sao Joaquthe in County Ordin Joaquin nance Nth District for a o. 549 for sewage or permit <br /> No. 1862 forcweil/dpump and the Rules and IRegulations of the Sao Joaquin <br /> Local Health District.//�� /��)./� fJ j�Q s �` <br /> 14(7,a <br /> / JLl/�e��S r( ��5.✓ Cityt os zJ'� '00 PM <br /> Job Address k <br /> (#E ill ��iP/� V/IGJJ�, ;4ddr 'Tt70 C.7 q1>'-S'l "hone J <br /> Owner's Name 4 <br /> Contractor � L Address 5r m if License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT LlDESTRUCTION C1 <br /> PUMP INSTA LATION ❑ SYSTEM REP OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL ROB REA CONSTRUCTION SPECIFICATIONS <br /> 6 Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pao ❑ Tr Type of Casing Specifications <br /> 0 Public ❑ Other 0 Delta Depth or Grout Seal Type of Grout_ - <br /> I I Irrigation x..Depth I I Eastern Surface Seal installed by - <br /> Repair Work Done 0 Type o1 Pump H.P. State Work Done_ <br /> Welt Destruction ❑ Well Diameter Sealing Material (top 50'{ <br /> Depth Filler Material (Below 5O) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AUDITION 1 1 DESTRUCTION ,No septic system permitted if public sewer is <br /> available within 200 feel.( <br /> • Installation will serve: Rsidence Commercial! Other <br /> Number of living units: 1 Number of bedrooms._77 .—. <br /> Character of soil to a depth of 3 testi` 'ie CoBw Water table depth <br /> SEPTIC TANK .$ Type/Mfg 9�;2A TCllerr77� Capacity—AP-47 No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal V' <br /> Distance to nearest: Well Foundation Property Line /r7 <br /> LEACHING LINE 0 No. & Length of lines Total length/size G <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 7 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify,that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Hoare owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"1 certify,that in the performance of the work for which this permit is issued.I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> ` ( The appiirant must call all required i pections. Corgplete drawing on 17 side. <br /> _ Title: Date: 4?- /� <br /> Signed Xy <br /> FOR DEPARTMENT USE ONLY / <br /> Date �` — Area <br /> Application Accepted by (j` y <br /> Pit or Grout Inspection f� Data Final Inspection by yam' ` Data pp <br /> � O \ezr�t � El lJ¢aderf <br /> Additional Comments: A <br /> ❑ Stk 466.6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> . Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. <br /> INFO 4 \ ^; ( ny, (�Y <br /> ..EH I}N IREy.rice( 3 `y.W ✓�. "�` /-.13�0 " <br /> EH 1t-26 p <br /> �O <br />